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Anaesthesia 2012, 67, 793–806

Correspondence Limited pre-operative echocardiography: are the limitations justified? We read with interest the article by Loxdale et al. on the routine preoperative use of transthoracic echocardiography in patients with a hip fracture [1], and would like to make some observations. Their technique omits reporting of the right ventricle, non-aortic valves and diastole. Right ventricular dysfunction is a strong and independent predictor of mortality in left ventricular dysfunction, and is associated with increased peri-operative morbidity and mortality in aortic stenosis [2]. In the age range of Loxdale et al.’s study, valvular disease is common and only one third is aortic stenosis [3]. Moderate or severe mitral regurgitation is commonly associated with poor left ventricular function, correlates with postoperative cardiac morbidity [4] and even with a normal left ventricular ejection fraction may lead to impaired contractile reserve [5]. With regard to diastole, half of patients with congestive heart failure have normal systolic function, and half undergoing cardiac or non-car-

diac procedures have abnormal diastolic function [6]. Pre-operative asymptomatic ventricular dysfunction is associated with increased 30–day and long-term mortality and morbidity, and diastolic assessment provides incremental prognostic value over systolic assessment [6]. We therefore suggest that clinically relevant peri-operative assessments have been omitted. The authors did not state how left ventricular ejection fraction was assessed nor if the same technique was used by all operators. Four standard methods (Simpson’s biplane, Teicholz, wall-motion scoring and ‘eyeballing’) are poorly interchangeable [7]. The first two do not correlate well with left ventricular ejection fraction in left ventricular hypertrophy [8] and are affected differently by permanent cardiac pacing [9]. Both conditions are prevalent in this patient group. Finally, we wonder why assessment of aortic stenosis was limited to the peak gradient which, as the authors say, can be misleading in low cardiac output states and is recognised as a poor measure of aortic stenosis when used in isolation [10].

Although focused transthoracic echocardiography is widely taught, we must be careful that limiting the breadth of our studies does not broaden our definition of ‘normal’. We are uneasy about the comment that ‘‘in the 96 patients where a murmur was heard, 30 (31%) had a normal echocardiogram’’ given the limited data presented. Although the authors demonstrate pre-operative data (time to theatre, influence on consultations and anaesthetic technique), they report no postoperative data on patient outcome. We consider this the most important marker. T. Dawes Hammersmith Hospital London, UK Email: [email protected] A. Alexiou Royal Free Hampstead NHS Trust London, UK No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesia correspondence.com.

References 1. Loxdale SJ, Sneyd JR, Donovan A, Werrett G, Viira DJ. The role of routine preoperative echocardiography in detecting

A response to a previously published article or letter must be submitted via the dedicated correspondence website at www.anaesthesiacorrespondence.com, following the guidance there and using the online form (not uploaded as a Word attachment). Please note that a selection of this correspondence will be reproduced (possibly in modified form) in the Journal. Correspondence on new topics should be submitted as an email attachment to [email protected]. Copy should be prepared in the usual style of the Correspondence section. Authors must follow the Guidance for Authors at wileyonlinelibrary.com/journal/ anae, including completion and submission of an Author Declaration Form. Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland

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aortic stenosis in patients with a hip fracture. Anaesthesia 2012; 67: 51–4. Pai RG, Varadarajan P, Kapoor N, Bansal RC. Aortic valve replacement improves survival in severe aortic stenosis associated with severe pulmonary hypertension. Annals of Thoracic Surgery 2007; 84: 85–6. Iunga B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. European Heart Journal 2003; 24: 1231–43. Koelling TM, Aaronson KD, Cody RJ, Bach DS, Armstrong WF. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. American Heart Journal 2002; 144: 524. Starling MR. Effects of valve surgery on left ventricular contractile function in patients with long-term mitral regurgitation. Circulation 1995; 92: 811–8. Matyal R, Skubas NJ, Shernan SK, Mahmood F. Perioperative assessment of diastolic dysfunction. Anesthesia and Analgesia 2011; 113: 449–72. Self S, Allen J, Oxborough D. Echocardiographic methods for quantification of left ventricular ejection fraction: are they interchangeable? Ultrasound 2010; 18: 73–81. Wandt B, Bojo L, Tolagen K, Wranne B. Echocardiographic assessment of ejection fraction in left ventricular hypertrophy. Heart 1999; 82: 192–8. Thackraya SDR, Wright GA, Wittea KKA, et al. The effect of ventricular pacing on measurements of left ventricular function: a comparison between echocardiographic methods and with radionuclide ventriculography. European Journal of Echocardiography 2006; 7: 284–92. Griffith MJ, Carey C, Coltart DJ, Jenkins BS, Webb-Peploe MM. Inaccuracies in using aortic valve gradients alone to grade severity of aortic stenosis. British Heart Journal 1989; 62: 372–8. doi: 10.1111/j.1365-2044.2012.07180.x

Echocardiographic assessment by anaesthetists We read with interest the article by Loxdale et al. [1]. In unselected patients with a hip fracture, they found that 8% of patients have moderate or severe aortic stenosis and that 7% have moderate or severe 794

Correspondence

impairment of left ventricular function. Moreover, they found that detection of a murmur does not predict the presence of valvular disease and that patients could have valvular disease without a murmur detected. Therefore, a pre-operative echocardiogram appears necessary before anaesthesia in this elderly population and the results may have significant implications for subsequent anaesthetic management [2]. Nevertheless, obtaining an echocardiogram may be difficult and the delay between hip fracture and surgery may negatively affect patient outcome [3]. Anaesthetists use ultrasonography to guide peripheral nerve blockade or central venous catheter insertion. They should probably learn to perform bedside echocardiograghy; they have learnt to detect murmurs with a stethoscope. Transthoracic echocardiography may complete the patients’ examination and it could reduce the waiting time before surgery in many cases. After brief formal training, intensivists can successfully perform and correctly interpret a limited transthoracic echocardiography examination in critically ill patients [4]. In our unit, some anaesthetists have learnt to perform echocardiography; they may not be as skilled as cardiologists but assessment of ejection fraction and detection of aortic stenosis is a reasonable goal. Finally, continuous spinal anaesthesia may be an interesting alternative, when a full cardiac examination with transthoracic echocardiography cannot be performed. Titrated bupivacaine injected through an intrathecal catheter provides more hemodynamic stability than a ‘single-shot’ spinal anaesthetic [5]. This technique

is safe and effective in patients with valvular heart disease [6].

L. Lonjaret O. Lairez V. Minville Toulouse University Hospital Toulouse, France Email: [email protected]

No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www. anaesthesiacorrespondence.com.

References 1. Loxdale SJ, Sneyd JR, Donovan A, Werrett G, Viira DJ. The role of routine pre-operative bedside echocardiography in detecting aortic stenosis in patients with a hip fracture. Anaesthesia 2012; 67: 51–54. 2. McBrien ME, Heyburn G, Stevenson M, et al. Previously undiagnosed aortic stenosis revealed by auscultation in the hip fracture population – echocardiographic findings, management and outcome. Anaesthesia 2009; 64: 863–70. 3. O’hEireamhoin S, Beyer T, Ahmed M, Mulhall KJ. The role of preoperative cardiac investigation in emergency hip surgery. Journal of Trauma and Acute Care Surgery 2011; 71: 1345–7. 4. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. Journal of Cardiothoracic and Vascular Anesthesia 2005; 19: 155–9. 5. Minville V, Fourcade O, Grousset D, et al. Spinal anesthesia using single injection small-dose bupivacaine versus continuous catheter injection techniques for surgical repair of hip fracture in elderly patients. Anesthesia and Analgesia 2006; 102: 1559–63. 6. Fuzier R, Murat O, Gilbert ML, Magues JP, Fourcade O. Continuous spinal anesthesia for femoral fracture in two patients with severe aortic stenosis. Annales Françaises d’Anesthésie et de Réanimation 2006; 25: 528–31. doi: 10.1111/j.1365-2044.2012.07181.x

Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland